MEDICAL POWER OF ATTORNEY
1. _____________________ (Youth Participant) is participating in a youth activity
sponsored by the Calvary United Methodist Church of Annapolis, Maryland (the “Church”).
2. During the Youth Activity the Youth Participant may need emergency medical care.
3. This Medical Power of Attorney is being executed by the parent(s) or guardian of the
KNOW ALL MEN BY THESE PRESENTS, THAT I/WE, ________________________
of _____________________ County, Maryland being desirous of appointing an Attorney in Fact
to Act for me/us and on our/my behalf in any and all matters relating to the emergency medical
care of ____________________ (Youth Participant) during a Youth Activity of the Church, do
hereby nominate, constitute and appoint Philip Cantrell or the designated Youth Leader of
Calvary United Methodist Church, State of Maryland, my/our true and lawful Attorney in Fact to
have full power in loco parentis in my/our absence or unavailability, during the time this Youth
Participant is actively engaged in the Youth Activity, to authorize or withdraw any medical or
dental treatment or diagnosis (including surgery) which he/she deems in the best interests of the
health and welfare of my above-mentioned Youth Participant, to the same extent as I/we could if
By virtue of these presents, I/we hereby ratify and confirm whatsoever my/our attorney
shall and may do pursuant to the powers and authority herein set forth; and the authority to act
under this Medical Power of Attorney shall not be effected by any disability of the udersigned,
but shall continue in full force and effect during such disability.
Signature of Parent or guardian Date
Emergency Medical Information: (example: medications my child is on, previous surgeries,
Emergency contact information: